WamBamThAmbulance

The incredible, shrinking, candied penis

At madness: tales of an emergency room nurse, there's a story of a new treatment for priapism:  sugar. 

'The First Billion . . .'

The First Billion Is The Hardest by T. Boone Pickens is highly recommended reading.  Though this book is not even remotely related to anything EMS-ish, it tells the story of Pickens's amazing experiences in business & investing -- fantastic wins followed by even more fantastic losses -- losses whose hunger was viciously quelled by victories of scale never before imaginable. 

Pickens puts all the cards on the table to lay-out in plain English the status of our energy problem, how it got that way, what'll happen if we don't fix it now, and feasible suggestions for getting rid of our energy problems once & for all. 

If I were Obama, I'd create a new position & appoint Pickens:  Czar of Energy & Natural Resources.  As Pickens mentions in the book, a position of the Czar type has clear & total authority over specific issues, enabling him to act & then ask questions later.

In the same fashion that the US President is Commander-in-Chief of the Military during a war, an energy Czar could employ dictatorial methods if needed to accomplish the goals.  Pickens never so much as hints about his being the energy Czar -- that's my idea. 

Mentioning the war makes me shudder, but it's an important point: we're burning billions of dollars every year on the war effort(s), but we're exporting trillions of our dollars on oil & energy.  We allow the issue with the most at stake (energy crisis) to get bogged down in bureaucratic BS; if a Czar were appointed, we'd be on our way yesterday.

Best nonfiction book I've read in a while.  I highly recommend it.

Bookworm

Paramedic Supermonkey managed to pull me from the daze of having just wrapped up clinicals & Team Lead; he's granted me the Bookworm Award.  Amazingly Paramedic Supermonkey hadn't forgotten my existence, even when I myself was beginning to wonder who I am, where I am, and what the hell's going on.  Thanks, dude!

So, the Bookworm Award.  Rules:Pass it on to five other bloggers, and tell them to open the nearest book to page 56. Write out the fifth sentence on that page, and also the next two to five sentences. The CLOSEST BOOK, NOT YOUR FAVORITE, OR MOST INTELLECTUAL!

My book:  JPod by Douglas Coupland (happens to be sitting right here on my desk, even though I finished reading it a millenia ago). 

"Why is he acting so strangely, then?"

"Maybe you're the one acting weird, and he's just feeding it back to you."

"I just drove up the hill to make sure Tim's body was still covered up."

"And . . . ?"

"They've already backfilled the area."

"That's a relief."

"I miss him."

"Mom, not here, not now."

"Can I come see you?"

"At work?"

The five other bloggers to whom I pass the Bookworm Award:

Boobs, Injuries, and Dr. Pepper

Street Watch: Notes of a Paramedic

Musings of a Highly Trained Monkey

Backboards and Band-Aids

Meat in the Seat

Roll over go boom

Jeep vs. concrete light pole.



It's not easily evident from this picture, but this street has a really sharp curve to the left.  This accident occurred approximately midway through the curve.  Apparently the 17yo driver was a bit too eager to get wherever he was going, lost control, and flipped while colliding with a concrete light pole. 

Near the front bumper of the vehicle is a dude in a white shirt -- he's from the local utility company & is dismantling what remains of the base of the light pole.  Just above his right heel you can see a big chunk of the concrete light pole laying on the ground. 

About another Jeep's-length to the right sits a single-story residence.  If it weren't for the light pole, the Jeep probably would have landed somewhere in the living room or kitchen.

Oh, PS -- no, there was no garage sale going on @ the time of the accident.  All that sh*t was in dude's Jeep. 

There were four other kids in the Jeep.  Only one of them was restrained.  They all escaped with only bumps & bruises, and all were ambulatory on scene -- amazingly.  Of course I took advantage of a "teachable moment" with the driver & with the passengers and scared them into ALWAYS wearing seat belts from now on. 

Honest study, honest paramedicine.

... a fire recruit laughs at me b/c my clinicals are taking so long,
saying he's never seen an honest paramedic student ...

Honest Study
I was @ the fire station doing the last bit of Team Lead rotations, hanging out in the apparatus bay with my preceptor, the Recruit, and a few of the firefighters.  The recruit asked when I'd started clinicals, and I answered, "oh, about this time last year."

He laughed, as if to say, 'dude, you're actually doing all of your clinicals?!'  He bragged that he finished clinicals in about two months; he then said he'd never actually met an honest paramedic student. 

He went on to describe the requirements of the paramedic program in Michigan & that they were next to impossible -- no doubt an attempt to justify the creative paperwork produced by him & other students in the Michigan program - fudged paperwork that bought them the end of their clinical rotations.

The Michigan clinical requirements are no more demanding than the ones in my home state.

Amazingly, he -- and others like him -- LIE about their clinical progress, then go on to pass the Practical and the NREMT-P exam. 

I'm further amazed that someone wouldn't be scared to death to proceed toward paramedic licensure without having been exposed to as many "practice" (clinical) encounters as possible. 

If it were all about taking a class & then passing a test, the Powers that Be wouldn't bother creating intensely demanding clinical rotation requirements.  Can the importance of clinicals be measured by the the fact that they are so demanding?  Isn't there a reason that (when done properly) more time is spent doing clinical rotations than is spent in the classroom?

Honest Paramedicine
If a student goes to the lengths necessary to create fictitious clinical paperwork, the stage has been set for the remainder of his career.  How can that person later be trusted to document accurate information on a Patient Care Report?  Trusted with prescription medication -- some of which includes narcotics?  Trusted to carry-out the Standard of Care (not just document that they've done such)?

One who cuts corners prior-to or post- licensure does so to the detriment of his own career & the communities he's supposed to support; it tarnishes the profession as a whole & is shameful indeed.

New Life

Just had my second EMS OB call. 24yo. Contractions three minutes apart. Grava 5 Para 3. Babe is at 32 weeks. IV access, oxygen, transport (quickly but carefully). She told me I did a good job :-) The fact that "paramedic student" is embroidered on my shirt probably had something to do with receiving that complement. Don't have a lot of experience with OB, so it's nice to know I don't appear as awkward as I feel.

Medication Combo Seems Weird

This combination of meds seems a little weird to me: Lithium, Cymbalta, Xanax, Clonazepam, Adipex. I asked her if she was keeping all of her doctors in the loop on what each was prescribing, and she said she just sees one doc. There have got to be some interactions going on here. I'll research this stuff later and post a continuation.

Auto-Eject Shoreline!

OMG. We finally get the auto-eject shoreline. I guess management got tired of folks ripping the old twist-lock shorelines out of the side of the units.

Exhaustion.

I'm exhausted lately. I've been doing my regular twenty-four hour thing on B shift, plus doing Team Lead for school on C shift. Luckily Team Lead is only 7am to 11pm - except for this Friday. This Friday I'll be doing the whole shift on a high-volume unit in an interesting part of town. Same part of town where I had the shooting and child birth the other day.

Firsts

Tonight has been a night of firsts. First major gunshot wound. First labor and delivery.

Shootings

Tonight's the night for shootings in the Bluff City.

The Little Pine Cone that Could

I realized WAY later in the day that the resolution on my phone's camera was set incorrectly, and by that time it was too dark outside to get a decent picture. Hopefully the tiny dark spot on the bumper is somewhat visible.

During a run earlier in the day -- probable around 0930 or 1000 -- I was closing the rear doors of our unit when one of them brushed against a tree branch overhead, knocking loose this pine cone. It's 1800-ish as I take these pictures; five or six calls later, and the pine cone is laying in nearly the same spot in which it originally landed.

This poor lil guy has been hangin on to the bumper all day & has barely moved an inch! Incredibly surprising considering the fact that we've repeatedly trekked from one side of the city to the other, and this is one of the big International units -- the Internationals bounce around so much they might as well have square wheels.

I've dubbed him, "The Little Pine Cone that Could," in spirit of a children's book with a similar title.

Wonder if Little Pine Cone will be there in the morning when I arrive?

Epi-Only vs. Epi+Vasopressin REMATCH!

The Source

Gueugniaud, P., M.D., et al. (2008).  Vasopressin and Epinephrine vs. Epinephrine Alone in Cardiopulmonary Resuscitation.  New England Journal of Medicine, 359(1), 21-30.  Retrieved from http://content.nejm.org/cgi/content/full/359/1/21.

Background

During ACLS for resuscitation from cardiac arrest, a combination of vasopressin and epinephrine may be more effective than epinephrine alone; however, there is not enough evidence to support one treatment modality over the other.

Methods

• Prospective study in which participants consisted of randomly-assigned adults (i.e., age 18+) with out-of-hospital cardiac arrest of non-traumatic etiology.
  • Group 1:  round(s) of 1 mg Epinephrine + 40 IU vasopressin; 
  • Group 2:  round(s) of 1 mg Epinephrine + saline placebo.
• In both groups, if no return of spontaneous circulation was seen, the same combination was given again.  Additionally, administration of amiodarone and/or fibrinolytic therapy was allowable and was at the discretion of the physician.
• End Point, Primary -- survival to hospital admission;
• End Points, Individual Secondary -- ROSC; survival to hospital discharge; good neurologic recovery; one-year survival post resuscitation.

Results

• No significant differences between the groups (with the exception of neurologic outcome)
• Survival to hospital admit:  20.7% combo group vs. 21.3 epi-only
• ROSC:  28.6% vs. 29.5%
• Survival to hospital discharge:  1.7% vs. 2.3%
• One-year survival:  1.3% vs 2.1%
• Good neurologic recovery:  37.5% vs. 51.5%
  (what "good" means, I'm not sure) 
  

Conclusion

• Combination of Epinephrine + Vasopressin does not improve outcome over epinephrine alone. 
• Patients experiencing witnessed cardiac arrest survived 23.2% of the time, whereas those experiencing unwitnessed arrest survived only 14.4% of the time.
• A notable difference became evident in a post-hoc subgroup analysis of PEA patients specifically:  the rate of survival to hospital discharge was 5.8% when the patient received only epinephrine; none of the subgroup patients receiving epinephrine + vasopressin survived to hospital discharge.

This Student's Opinion

• Having reviewed this study after a similar one which used porcine participants, it is evident that this study is much more applicable and relevant. 
• Successful resuscitation requires a delicate juggling & tweaking of variables, many of which are beyond our control. 
• Out-of-hospital resuscitation carries its own set of unique challenges; principally, time is of the essence. 
• Adding a step for which there is no clearly demonstrated benefit (i.e., adding vasopressin to the mix) causes the window of opportunity to shrink. 
• Based on this article, it could be argued that vasopressin has failed to make the cut & deserves no time on the resuscitation stage.

waiting-room vending rip-off

Our FF-EMT driver was hungry & ventured to the E.D. waiting room to check out the vending.

Small Bag of Ruffles Cheddar / Sour Cream chips:  $1.00. 

WTF

Is it too late to abandon the path to paramedicine & go into vending instead?

Light @ the end of the tunnel

I'm finally at a point where I can put a number on how much is left on my path to paramedicine. 

I've got 26 patient contacts remaining; I'm going to 'fluff' that to 36, though, just in case there's something wrong with my paperwork somewhere along the line.  Adding ten (doing more than required) will give me some wiggle room.

I've been working on the comprehensive exam (it's done online).

After that, it's the practical; then the national exam.

I've been neglecting the blog for two reasons:  (a) my creative energy has been focused on getting done with this school stuff;  and (b) there's been an absence of interesting stuff to write about.

I'm not gone.  I promise.

thanks for reading.